Infertility or subfertility could be a problem for people afflicted therewith. A common treatment of infertile women is IVF (in vitro fertilization) treatment. The basis of the IVF treatment is as follows:
Stimulation of ovulation: Daily hormonal injections, ultrasound examinations and blood samples.
Oocyte retrieval: Ultrasound guided ovarian punctures performed vaginally in local anesthesia.
Preparation of spermatozoa: Swim-up, swim-down, sperm select or other methods to select the optimal population with the best progressive motility.
In vitro fertilization: Incubation of oocytes and the selected population of spermatozoa in a cell incubator. Direct microscopic inspection of cell division and selection of the most vital blastocyte.
Embryo transfer: 2-3 blastocytes with the best vitality is deposited in the uterine cavity for hopeful implantation in the endometrium.
IVF treatment is an expensive method that for some couples initiates complicated psychological side effects. The technical and artificial way of trying to become pregnant has the disadvantages for the couple going through the treatment which may adversely affect the relationship. After all the troublesome treatment there is only a pregnancy rate of 25-30%, leaving those who did not succeed with a damaged relationship and still no child. The cost for IVF treatment is around 20 000-25 000 SEK per menstrual cycle.
In spite of several previous investigations the reasons for infertility during endometriosis is not clear and neither is the lack of improved fertility rate after treatment. Particularly the relationship is unclear between mild endometriosis and subfertility in the absence of pelvic adhesions (Mahmood, T A, Templeton A. Patophysiology of mild endometriosis: review of literature. Human Reproduction 1990; 5:765-784).
Increased numbers of leukocytes has been found in the peritoneal fluid (PF) from patients with endometrial peritoneal implants and has been considered as an ongoing sterile inflammation (Haney A F, Muscato J J, Weinberg J B: Peritoneal fluid cell populations in infertility patients. Fertil Steril 1981, 35:696-698; Edelstam GAB, Lundkvist O E, Venge P, Laurent T C: Hyaluronan and myeloperoxidase in the peritoneal fluid during genital inflammation. Inflammation 1994, 18:13-21). The increased number of leukocytes contain in vivo primed macrophages secreting a macrophage derived growth factor (MDGF) that may explain the proliferation of the endometrial tissue (Halme J, White C, Kauma S, Estes J, Haskill S. Peritoneal macrophages from patients with endometriosis release growth factor activity in Vitro. J Clin Endocrin and Metabolism. 1988;66:1044-49). Other secretory products from the macrophages, growth factors such as TNF and interferon, exhibit gamete toxicity and may also have an adverse impact on the fertility process (Halme J: Role of peritoneal inflammation in endometriosis-associated infertility. Ann N Y Acad Sci 1991; 622:266-74).
Also the cell-free peritoneal fluid is of importance in the reduced fecundity since it has been shown that it significantly reduces the ovum pick up capacity of the fimbriae of the fallopian tubes (Suginami H, Yano K, Watanbe K, Matsnura S: A factor inhibiting ovum capture by the oviductal fimbriae present in endometriosis peritoneal fluid. Fertil Steril 1986; 46:1140-1146). In peritoneal fluid from patients with endometriosis and unexplained infertility respectively a reduced progressive velocity of spermatozoa has been found (Makarand K, Oak M, Chantler E N, Vaughan Williams C A, Elstein M. Sperm survival studies in peritoneal fluid from infertile women with endometriosis and unexplained infertility. Clinical reproduction and fertility 1985; 3:297-303.). Even more interesting is the increased phagocytosis of spermatozoa that has been found during incubations for 24 h in vitro with peritoneal fluid from patients with endometriosis (Muscato J J, Haney A F, Weinberg J B, Sperm phagocytosis by human peritoneal macrophages: a possible cause of infertility in endometriosis. Am J Obstet Gynecol 1982; 144: 503-510). In that particular study there were however several different sperm donors and therefore immunological factors involved cannot be excluded.